General Assistance Online Application

Personal Information

Instructions

Please enter the information for the person applying for assistance!

Contact Information

Phone Number

Current Address

Mailing Address

Address History

Instructions

List your previous addresses for the last 12 months.

Line 1 Line 2 City State Zip County Moved In Moved Out Evicted?

Family Members

Instructions

Please list all members of the household (children in the home full-time, relatives, roommates, etc.)

Name SSN Birthdate Relationship Race Gender Marital Status

Family Questions

Request Details

Housing

Utilities

Utility Type Company Name on Account Account # Pay Arrangement? Disconnection Notice?

Income

Name Income Type Amount (Last 30 Days)

Terms & Conditions

I understand that the information I provide to Polk County Department of Community; Family & Youth Services is used to determine my household's eligibility for General Assistance. This information will be kept confidential as it is required by Iowa law except to the extent that I authorize its use. I hereby authorize the Polk County Department of Community, Family & Youth Services to release the information I have provided, including use of my social security number, for the purpose of checking the accuracy of the information I have provided, to verify my income as reported by the Workforce Development Center, and to determine my eligibility for General Assistance. I also authorize the Polk County Department of Community, Family & Youth Services to inform vendors to who assistance would be paid on my behalf, including my landlord , whether my application for assistance has been approved or denied.

I solemnly swear that the statements I made are true and correct to the best of my knowledge and belief. I am aware that it is unlawful to give false information.
I understand that any willful misrepresentation of the information provided may result in a court action against those persons who have fraudulently participated in the General Assistance Program.

Polk County Department of CFYS shall not discriminate against any person because of race, color, religion, creed, sex, sexual orientation, gender identity, age, national origin, generic information, disability, or veteran or military status.

The Polk County General Assistance Denial is valid for any and all requests within the month of which you have applied for assistance.


This is considered an electronic signature